99070023FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO
BUILeuvcDIVISION APPLICATIONIPERMIT PI.US1nFNG"MECHANICAL
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❑ Consultant Fees Paid by Applicant (Initial)
BUILDING PERMIT INFO
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LICENSED CONTRACTOR'S DECLARATION
1 hereby allirm Ih t I um licensed under provision. of Chapter 9 (commencing
Section 7")of Division 3 ofthe Business and Professions Cale, and my license is
y
full force andeup �3/
a s Lic.nAPPLIANCES-RFSIDENfIN.
ate Cont n'nrt
QTY ELECTRIC PERMIT FEE
JOB DESCRIPTION
RESIDENTIAL,
❑SFOWL ❑ KITCHEN REMODEL
❑AUDITION' ❑PWMBING HIi-PIPE
❑MUl:fl-UNIT ❑STRUCTURAL.
MODIFICATION
❑INTERIOR El CHIMNEY REPAIR
1'I:RMITISSUANCE. 5 /
RCHITECTS DECLARATION
I undeamnJ my plain shall be used an public unrds
I'ANIihS
lll'T02111)AMPS
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LicemeJ Pmfensamul
OWNER -BUILDER DECLARATION
1 hereby affirm ,hat 1 am exempt fmm the Contmcmr's Lici n.+e Low beatific
following reason. (Section )0315, Business and professions Cade: Any city or county
which requires a permit to construct, its, improve, demolish, or repair any nmemre
prior brit,issuance,olso requires the applicant for such Permit file a signed statement
201-1000AMPS
IMPROVEMENT ❑SWIMMING POOLS
❑ ATH RCMODE REPAIR ❑DEMO^
C
OVER 1000AMPS
SIGNS ELECTRICAL
SPECIALCIRCUIT/MISC
JJJJ
d�
that he is licenced pursuant to the provisions of the Contractor's Liaise Law (Chapter 9
CO
y o Iv
ISXI LLy
fcnmmencingwirh Sallnn 9lM)IB rFUlvisinn3afihc Ouninesnvnd Prnln.,innx Gele)nr
that he is exempt therefrom and the haxis for the alleged exemption. Any indiction of
Section]031.5 by any applicant for aperntil suhjcd+lhe applicant ucivil Penalty of
'HIMP. METER OR POLE INS'r. IP
COMMP.RCIAL:
EINE W BLDG/ADDITION El DEMOLITION
❑TENANT ❑ FOOD SERVICE
IvlwIiR DEVICES
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more than five hundred dollars (S500).
❑l, as ownerrf the prope�Y. or my employees with wegesmNeirenlmompen,atinn,
will do the work, and the sometime is not intended or offered frrsale(Sec.](W, Business
and Professions Cao: The Contractor's license Law does not apply to an owner of
progeny who builds or improves Human, and who does such work himself or through
his own employees, provided that such impmvennents ore not intended or offered far
sale. If, however. the hnilding or impmvemrnt is sold within one year in,ntiletion, the
IMPROVEMENT'
❑OTHER
SWIMMING POOLEI.I[CfRIC
/
OUTLETS - SWITCI a -FIXTURES l
NEW RESIDENTIAL ELECT R SQ FT'.
SQ. IT. FLOOR AREA
$ISQ, FI'.
ter -builder will have the burden of proving that he did not build or improve for pur-
TOTAL:
pew of role.).
❑ 1. as owner of the prapeny am exclusively contracting with licensed! contmctrrs to
construct the project (Sec. ]led. Business and Professions Code:) The Contmnoes Li-
xeLaw does net apply as an ownsrnf pmpeny who builds n mprovesdaveron.unit
QTY. PLUMBING PERMIT FEE
who contracts for such projects with a contractor(s) licensed punm d to IM Contmetmes
1117RMIT ISSUANCE
License law.
❑ 1 ran exempt ander Sts. , B & P C for this reason
Owner Dat,
Aid 17R - DRAIN & VENT- WATER EA)
VALUATION
WORKERS COMPENSKI'ION DECLARATION
hereby
HACK FLOW PROTI!CT. DEVICE
1 off nn under penalty of perjury one of the following dedmariann:
STORIES
TYPECONSTRUCTION
❑ Ihaveand willntuinmine Cenificateof Conwnuoselfinsumfor Wo)Aces ComWn-
sation, as provided for by Section 3](X1 of the Who Cade, far the performance of the
DRAINS- FLOOR, RODE', AS FB. COND.
wok far which this pso is issued.
FDTIIRES - PER TRAP
have and will maintain Worker's Compensation Insurance, as required by Section
3 oftheLabor Code, hot he pedmidemeof the work list which this permit isin.mod.
OCCGROUP
APN
GAS- G. SYSTEM4 INC. 4 OUTLETS
My Worker's �, tpc inion Insurance carrier and Policy nyyyy her'rc
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Cnnier: Pnilcy Nn.:.µ.! E
GAS -EA. SYSTEM 4
WAiµ
I:T
GREASFIINDUSI'Rh WAS'IEINTERCEPTOk
B
CERTIFICATE EXEMPTION FRO WOR ERS' _
COM NSATIONINSURANCE
T
tlU1LDING DIVISION FEES
(Thi,schadinaddid becompdeted ifthc permit in fnfone hundred detlms(SIM)
or less.)
GR BASE TRAP
PLANCHECK FEE
SEWER -SANITARY- SI' ORM EA. 200 FT.
ENERGY FEE
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I certify that in the pefformance of the work for which this permit i. issued, (shalt
not employ any person in any manner so as m become subject m the Workers' ComMn-
n:Winn Laws of Culifnmio.lAle
Applicant I
NOTICE TO APPLICANT. If, after On Am, this Cetifcate of lixcmptinn, you should
became xaompym tothe Workers chIno Compcnr this Provisions steal of'he imalesbor Code eyou must
frnhwith comply with tech provision+or this permitfiallMdeemed rcvnkcJ.
CONSTRUCTION LENDING AGENCY
affirm that is a construction lending agency for the Px6or arce of
the work far which thin permit is issued (tie,, led), Civ. CJ
Lender, Name
WATER HEATER WNENPELECTR
WA'i'liR SYSTEM/fR1iA'1'INC,
GRADING FEE
SOILS FEE
WATER SERVICE
PAID
Date RaciplN
NEW RESIDENTIAL PLMB. Sp. FT.
TOTAL'
TOTAL:
Lenders Address
BUILDING FEE
nmwion is
1 certify Item 1 have read this application and sate that the above infr
camel. I agree to comply with all city and county ardlmnecs and one laws relating to
building constmetion, and hereby immorize representatives ofthis city to enter upon the
above-mentioned property for inspection purposes.
(We) agree to save, indemnify unit keep hmmless the City of Cupertino against
QTY. MECHANICAL PERMIT FEE
SIi15MIC FEE (J
PERMIT ISSUANCE 3V/
ELECTRIC PBT.
PLUMBING FEE
liabilities,judgments, costa and expenses which may in any wary accuse again, said City
in consequence NDF granting S this permit.
REUILAdIO TANIJS AND WILL COMPLY WITH ALI.NON-POINT
SOURCE'. REGULATIONS.
SOURCE
ALTER OR ADD TO MECIL
AIR HANDLING UNIT (TO 10,000 CFM)
MECHANICAL FEE
AIR HANDLING UNI '1'(OVER 10,000 CFM)
CONSTRUCTION TAX
Signature of ApplinnUCmlmcmr Date
EXHAUST HOOD(W/DUM)
HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
HF.AUNG UNIT CPO 000.001 BTU)
Will the applicant or future building occupant store or handle harraNnu.material
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safely
Code. Section 255320Ht
HEATING UNIT (OVER 100,000 BTU)
V 17NTILATION FANS I NGLE REM D)
❑Yen E] No
Will the applicant or future building Gccrpam use equipment or devices which
emit hoop us air contaminants as defined by the Bay Area Air Quality Management
PAID
DateRmeiplW
BOILER-COMP(311POR 11X),000 BTU)
TOTAL.
BOILER -COMP (OVER 100.000 BTU)
District?
E] Yes ❑No
AIR CONDITIONER m
ISSUANCE DATE
1 have it the hatamme muterialx requirements under, Chapter fi 95 of the Cali-
forma Health&Safety Cale, Sections 25505,25533 and 25534. I understand that if the
NEWRESIDENTIALMECIL SQ. FT'.
building ares not cmrnndy have a teaund lea it is my resper sihility In nudity the rccupznt
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ofthe reutdcmemywhivdwmsppe--teem Ansa I...ounce ofa Cenj(gmc of Occupa9fy.
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ICE